医药学论文：急性胆囊炎腹腔镜胆囊大部切除26例报告

【摘要】 目的 探讨急性胆囊炎行腹腔镜胆囊切除术中，遇到胆囊三角区严重粘连时，如何处理胆囊管及避免肝外胆管损伤的办法。方法 从1996年7月至今，共有2362例患者行腹腔镜胆囊切除术，回顾分析总结我科26例腹腔镜胆囊大部切除术的原因、方法、经验和体会。结果 24 例手术顺利完成，2例中转开腹，全无死亡，术中胆总管前壁被电刀点状灼伤1例致术后胆瘘，术后第6 天自行闭合。手术时间25～160min，平均105min。术中出血5～70ml，平均45ml。术后3～11 天痊愈出院，平均6.46天。随访3个月～3年，无症状复发，效果满意。结论 在化脓性胆囊炎或胆囊三角严重粘连疤痕化等不能够常规行胆囊切除的病人，行腹腔镜胆囊大部分切除术简便而安全可行，不但能够达到胆囊切除的目的，又能减少肝外胆管和血管损伤，避免了中转开腹;但必须严格掌握适应证，正确处理胆囊残余部分。

 

【关键词】 腹腔镜;胆囊大部切除术;胆囊切除术;胆囊炎

 

Analysis of laparoscopic partial cholecystectomy for 26 cases of acute cholecystitis

 

【Abstract】 Objective To explore handling measures of deal with ductus cysticus and avoiding extrahepatic bile duct to be impaired while Calot triangle severe adherence as acute cholecystitis in laparoscopic cholecystectomy.Methods 2362 cases who underwent laparoscopic cholecystectomy from July 1996 to now were collected and analyzed retrospectively. Twenty-six of them were performed partial cholecystectomy.Results Operation(24 cases) went on smoothly, conversion to open 2 cases.There were no cases of mortality. And common bile duct of anterior wall (1 cases) was injuried by electrode knife in operation,and it caused bile leak after operation.After 6 days， bile leak stoped. The mean operative time was 105 min (range，25～160min). The mean blood loss was 45ml (range，5～70ml ). The average time of hospitalization after operation was 6.46 days (range， 3～11 days). Follow - up lasted three months to three years. Their clinical manifestations had no recurrence. All 24 cases got satisfied effect.Conclusion It is a simple safe and feasible method. It can decrease the rate of external hepatic biliary ducts injury and avoid converting to open laparotomy. We must strictly master the indication and manage residue of cystic duct correctly.

 

【Key words】 laparoscope； partial cholecystectomy；cholecystectomy； cholecystitis

 

急性胆囊炎由于胆囊三角周围组织炎症水肿重或瘢痕粘连，正常的组织结构不易辨别，盲目解剖胆囊三角区，极易损伤胆总管、右肝管及门静脉。采用胆囊部分切除术，可以有效防止胆管损伤和出血， 且无明显后遗症，我科自1996 年7 月开展腹腔镜胆囊切除术(laparoscopic cholecystectomy， LC) 以来， 共行LC 2362 例，其中切除急性炎症期胆囊共225例，行胆囊大部分切除的有26例，效果满意，现分析总结如下。

 

1 临床资料

 

1.1 一般资料 本组26 例，男15例，女11例；年龄23～86 岁(59.3±15.6岁)。急性化脓性胆囊炎6 例；坏疽性胆囊炎4例，其中胆囊穿孔2例；慢性胆囊炎急性发作12 例；Mirizzi综合征4例（Ⅰ型2例，Ⅱ型2例）。合并胆囊结石者23例，其中胆囊颈结石嵌顿者5例；胆囊管闭塞形成胆囊积液积脓，胆囊内无正常胆汁者11例；合并胆囊癌者1例；无结石者3例。急性期病程1～15天(6.8±3.5天)。

 

1.2 术前准备 所有病例术前常规行超声和（或）CT检查以明确诊断。对有黄疸史或伴黄疸者行十二指肠镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography，ERCP)或磁共振胆道成像(magnetic resonance cholangiopancreatography，MRCP)检查以除外肿瘤等胆管占位病变。伴胆总管结石者术前行十二指肠镜下奥狄括约肌切开取石术（endoscopic sphincterotomy，EST)。入院后即给予抗感染、解痉治疗，纠正离子紊乱，如合并有糖尿病、高血压等疾病，则给予对症治疗。